“No Jab No Pay” A questionable main course with some excellent side dishes.

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Today the Australian senate passed new laws that stop parents who object to vaccination from claiming family assistance payments. The Social Services Legislation Amendment (No Jab, No Pay) Bill 2015 passed. This blog addresses some misconceptions and tries to summarise how each aspect will affect different people.

Disclaimer: I have tried to be as accurate as possible but please check anything affecting you with the relevant government websites.

“No Jab No Pay” is not a new incentive system.

There is much confusion about this policy proposal. First, it has been confused with state-based reforms. Put simply, the federal government can control access to family assistance payments through No Jab No Pay. The state and territory governments can potentially control access to childcare through No Jab No Play. Different states and territories have different requirements, with Victoria and QLD having the harshest ones and NSW having the most reasonable approach. So check your state health department website.

Second, “No Jab No Pay” has been assumed to be a new vaccination incentive system for Australia. It is not. Australia has had ‘no jab no pay’ requirements since 1999. See this article for an overview. Any child born between 1999 and today had to be age-appropriately vaccinated for their parents to receive family assistance payments. If they were not, their parents had to lodge an exemption – either a medical or ‘conscientious objection’. A doctor or immunisation provider had to sign the form saying:

“I have explained the benefits and risks associated with immunisation to the parent or guardian of the child named, and have informed him/her of the potential dangers if a child is not immunised.”

If parents did not meet these immunisation or exemption requirements, they would miss out on receiving the payments. The payments linked to vaccinations have been:

Family Tax Benefit Part A supplement when they turned 1, 2 and 5 years (income tested).

What will change?

Removes the conscientious objection exemption so those families can’t get the payments at all;

Extends the ‘fully vaccinated’ requirement to age 19. (This is for the vaccines that are due by age 5 years — it doesn’t pertain to HPV vaccine which is first given at 12 or 13 years);

Applies the requirement each income year from age 1 to 19 years, not just at 1, 2 and 5 years.

Will it work?

The bill in its entirety will hopefully improve vaccination rates, probably because of the added extras. When the policy was announced by Scott Morrison on 12 April, I wrote this blog expressing concerns that it would not make a meaningful difference to vaccination rates. In the form that was announced at the time, it would not. But government has since announced additional changes that will have more of an impact.

A decline in objector rates happening now has been assumed to be a result of people already re-thinking their decision. Maybe but we don’t know if they have actually vaccinated. They may have simply stopped their objection registration. Vaccinations rates are what we should look at and even then, commentators should be careful not to fall into the ecological fallacy trap and attribute a changes in rates to any one thing.

Main course: Removing conscientious objection exemption

Positives

Could increase vaccination rates by 0.6% if all affected objectors are fully vaccinated. However, not all will change and some will dig in.

Saves an estimated $200 million from people not getting family payments because they will still refuse vaccination. This pays for the good measures.

All the media attention could act like a giant advertisement for the existing requirements.

Negatives

This group is now 1.52% of all children. Still doesn’t deal with the 7% who don’t lodge objection and don’t get fully vaccinated.

Doesn’t really touch the wealthy objectors.

Families could miss out on up to $14,000 per year per child.

Creates financial hardship for very low income families among the objectors.

Will make childcare unaffordable for some families who continue to refuse vaccination.

Undermines the consent process and reduces trust in the system.

GPs and nurses will be at the frontline of conflict.

Removes incentive to get a form signed by a health professional meaning less engagement with health care system.

No more monitoring rates of vaccine objection. It disappears as an entity.

Removes system that some state governments used to enable access to childcare for vaccine objectors.

Verdict

An ethically questionable approach to the problem. A better option would be to require yearly registration of objection until child turned 5. However, this part of the bill will fund some more effective reforms.

Still no system to compensate for rare and serious vaccine injury.

Will need to find other ways to measure vaccine objection.*

Side dish: Yearly requirement to be up-to-date with vaccinations.

Positives

Each year, parents will be reminded to get their children up to date with the vaccinations. Before, it was only when child turned 1,2 and 5 years of age.

Health Department is funding catch-up vaccines for a time for the over-7’s. They were previously not free.

Negatives

Could affect lower income families much more.

Verdict

A yearly vaccination nudge will get parents to be a bit more timely with vaccinations.

Side dish: Expanding requirements to age 19

Positives

Ongoing yearly reminders for parents to get their kids up to date for the primary series given before age 5.

Necessitates the expansion of the immunisation register to 19 years in the first instance.

Negatives

Expands the application of the penalty for the disadvantaged who are struggling to access the services.

Creates a bit of a nightmare if the register isn’t recording vaccinations well.

Verdict

More children will get up to date and the gains will be sufficient to outweigh the negatives in my view.

On April 12, Minister for Social Services Scott Morrison announced No Jab No Pay – the stick – on April 11. Then on April 19 and later in the May budget, Minister for Health, Susan Ley announced some other reforms – the carrots.

Health Department side dish #1: Expanding the register from 0-7 to age 19 then to all ages by end of 2016

Positives

Enables health professionals and all Australians to know if they are due for a vaccine. No more digging around for lost vaccination cards…

Encourages health professionals to be looking out for opportunities to remind late parents. Some compensation for health professionals for the extra time to address often complex catch up arrangements.

Negatives

Addresses children who are late instead of targeting them before they become late.

Verdict

Worthwhile. A pre-vaccination reminder system would be nice too. Pre-call is better than recall.

Health Department side dish #3 Education and communication

Positives

Informs parents about all the changes.

Addresses a national gap of consumer information and education.

Addresses the vaccine hesitancy problem.

Increases support for health professionals dealing with vaccine hesitancy and refusal*

Negatives

Education and communication are essential but only increase vaccination rates if combined with other interventions.

Education can sometimes make things worse if done poorly.

Verdict

Fills a national gap. The communications should be based on understanding the different target groups, be evidence informed, and truly engage with people’s questions and concerns.

What about the ethics of No Jab No Pay?

In terms of removing capacity to claim objection and get family payments, many welcome this new ‘get tough on anti-vaxers’ approach. Others like me argue that many of the objectors will be unmoved. It will make their children pay twice and there are more ethical and effective ways to raise vaccination rates. Experts in Australia, the USA and UK have also raised their concerns about these kinds of measures. The Royal Australasian College of Physicians; The Public Health Association of Australia; the Australian Medical Association all raised concerns about aspects of the bill in senate submissions.

On the other hand, there are some knowledgeable and thoughtful people who mount arguments for removing objection provision from the current requirements.

I do not support the aspect of the bill that removes the capacity for vaccine refusers to obtain family assistance payments. However, other parts of the bill are positive additions that will probably improve vaccination rates. And here’s where it gets more complicated: the estimated $503 million over 5 years, save by the reforms not working on a bunch of parents, appears to be funding a whole of life register, a catch up payment for doctors who get late kids caught-up and some communication initiatives*. In particular, the register expansion and the catch up payment will certainly improve coverage because it targets the largest group of under-vaccinated: the 7% who don’t meet vaccination requirements and don’t lodge an exemption.

Whether government can justify such a severe policy depends on how much can be gained; the degree of harm; and what is in place to mitigate those harms. Right now, Australia has no compensation system for the very rare occasions where children are injured by vaccines. Fortunately, the senate recommended that it be investigated following our urgings. We must keep this on the agenda.

Regulation in public health has saved many lives. Seat belts, drink driving laws and indoor smoking are the stand-out examples. And while the alcohol and fast food industries could be better regulated, prohibition of alcohol was a failure. Shutting out the children of vaccine objectors from childcare through making it unaffordable (feds) or inaccessible (states) potentially creates a market for lower quality childcare arrangements for families who can no longer afford quality accredited ones. Such plans have already emerged in news reports.

Somebody has argued that if we can ban peanut butter sandwiches in schools, we can ban the unvaccinated. But children are not peanut butter sandwiches. They are children with a right to education and family support payments like any other eligible child. There are already rules in some states to exclude the unvaccinated during an outbreak. People are rightly concerned about risk of harm to others. But to be fair, the responsibility should be spread beyond the children of the unvaccinated: to ensure antenatal clinics offer pertussis and flu vaccines to pregnant women, to ask why only 36% of younger groups at risk of severe influenza are vaccinated for flu; and vaccination of childcare workers should be under the spotlight.

With vaccination, regulation works: linking to family payments since 1999 and other measures has taken national coverage from 53% to 92%. But we have a persistent 8% gap that is bigger in some regions. The children making up that gap need other measures. Some of the reforms around No Jab No Pay will help but more is needed.

*Conflict of interest: I am leading a program of research funded by the Department of Health through NCIRS that involves developing a communication support package for primary care providers. I have sought funds for research on measuring vaccine acceptance and conducting research in communities.